Documentation in Healthcare
•Download as PPTX, PDF•
0 likes•155 views
This document discusses the importance of documentation in healthcare. It covers why, when, how, who, and where documentation should occur. Documentation fosters quality care, continuity of care for patients, and effective communication between providers. It also establishes a legal record in case of lawsuits. The document emphasizes that documentation should occur at every point of contact with the patient using methods like SOAP notes. Proper documentation includes legible writing, signatures, and noting both positive and negative exam findings. Lack of documentation can result in legal penalties if complications occur but actions were not documented. Informed consent is also crucial and must be properly documented.
Report
Share
Report
Share
Recommended
shari monster2
Shari Morales is a certified medical assistant with over 10 years of experience providing patient care and administrative support in medical offices. She has strong communication skills and is adept at building rapport with patients. Her qualifications include experience with patient intake, vital sign collection, exam room preparation, basic lab procedures, medication administration, and electronic health records. She strives to ensure accurate information and compliance with health regulations in all aspects of patient care.
4 Critical Care Case Study
This case study describes the care of a patient who came into the hospital with sepsis and progressed to acute respiratory and renal failure requiring mechanical ventilation and a tracheostomy. The patient did not respond to any external stimuli except pain. Through researching the patient's conditions and monitoring lab values, the student was able to understand the pathophysiology and appropriately treat the patient's multiple organ dysfunction syndrome. The experience provided an opportunity for the student to learn how to communicate with and provide comfort to patients with limited response abilities.
Current Resume Christian
Michelle Downard has over 15 years of experience as a medical assistant with expertise in phlebotomy, injections, EKGs, physical exams, and various medical procedures. She has worked in urgent care, primary care, endocrinology, and family practice settings. Downard has a certificate as a clinical medical assistant and phlebotomist from A.C.T. College and advanced phlebotomy and IV therapy certificates from Medical Learning Center. She is proficient with EMR systems like Athena and e-clinical.
Dr Brian O'Doherty, GP Gorey
This document discusses strategies for improving primary care services with limited resources. It suggests that primary care centers should employ vocationally trained GPs with special interests, provide open access to services like radiology and phlebotomy, increase patient education, improve IT infrastructure, offer non-medical therapies, and strengthen referral pathways. The goal is to better manage patient expectations and needs, reduce medical inflation and workload on hospitals, and improve overall health outcomes with scarce resources.
Thai nhso palliative care payment
The document discusses palliative care transitions and payment models in Thailand. It outlines the continuum of care from early disease stages to end of life, including acute, post-acute, ambulatory, and home-based care. It also shows different payment methods used in Thailand, such as capitation, global budgets, fee schedules, pay-for-performance incentives, and episode-based payments to providers.
History Taking In a Patient with Hemophilia
(1) Mahmoud Bikheet Ahmed, a 12-year-old male student, presented with bluish discoloration around his left eye following trauma 2 days prior.
(2) He has a known history of hemophilia and received cryoprecipitate for swelling and limited vision in his left eye as well as hemarthrosis in his left knee and elbow.
(3) His past medical history is significant for severe bleeding after circumcision at 6 months old when he was diagnosed with hemophilia A, and treatment for hepatitis C.
Dr. RAHUL VC TIWARI, SIBAR INSTITUTE OF DENTAL SCIENCES, GUNTUR, ANDHRA PRADE...
Dr. RAHUL VC TIWARI, SIBAR INSTITUTE OF DENTAL SCIENCES, GUNTUR, ANDHRA PRADE...CLOVE Dental OMNI Hospitals Andhra Hospital
This document presents a case report of a 22-year-old male patient who experienced trauma to the right side of his face after a motorcycle accident 20 days prior. He presented with pain and swelling in his right lower jaw. Physical examination revealed a laceration on the right eyebrow that was healing, subconjunctival hemorrhage on the right side, and loss of the malar prominence on the right side. Radiological investigations showed a zygomatic complex fracture and mandibular angle fracture on the right side. The treatment plan was for open reduction and internal fixation surgery to repair the fractures.Jessica Resume
Jessica Hughes is an LPN with over 10 years of experience providing culturally competent care to diverse patients with various needs including hospice, palliative care, wound care, diabetes, stroke, and psychiatric patients. She has strong clinical and organizational skills including monitoring vitals, administering medications and treatments, assisting with admissions and care plans, and ensuring quality patient care. Her professional experience includes working as an LPN at various facilities such as VA medical centers, nursing care services, and assisted living facilities.
Recommended
shari monster2
Shari Morales is a certified medical assistant with over 10 years of experience providing patient care and administrative support in medical offices. She has strong communication skills and is adept at building rapport with patients. Her qualifications include experience with patient intake, vital sign collection, exam room preparation, basic lab procedures, medication administration, and electronic health records. She strives to ensure accurate information and compliance with health regulations in all aspects of patient care.
4 Critical Care Case Study
This case study describes the care of a patient who came into the hospital with sepsis and progressed to acute respiratory and renal failure requiring mechanical ventilation and a tracheostomy. The patient did not respond to any external stimuli except pain. Through researching the patient's conditions and monitoring lab values, the student was able to understand the pathophysiology and appropriately treat the patient's multiple organ dysfunction syndrome. The experience provided an opportunity for the student to learn how to communicate with and provide comfort to patients with limited response abilities.
Current Resume Christian
Michelle Downard has over 15 years of experience as a medical assistant with expertise in phlebotomy, injections, EKGs, physical exams, and various medical procedures. She has worked in urgent care, primary care, endocrinology, and family practice settings. Downard has a certificate as a clinical medical assistant and phlebotomist from A.C.T. College and advanced phlebotomy and IV therapy certificates from Medical Learning Center. She is proficient with EMR systems like Athena and e-clinical.
Dr Brian O'Doherty, GP Gorey
This document discusses strategies for improving primary care services with limited resources. It suggests that primary care centers should employ vocationally trained GPs with special interests, provide open access to services like radiology and phlebotomy, increase patient education, improve IT infrastructure, offer non-medical therapies, and strengthen referral pathways. The goal is to better manage patient expectations and needs, reduce medical inflation and workload on hospitals, and improve overall health outcomes with scarce resources.
Thai nhso palliative care payment
The document discusses palliative care transitions and payment models in Thailand. It outlines the continuum of care from early disease stages to end of life, including acute, post-acute, ambulatory, and home-based care. It also shows different payment methods used in Thailand, such as capitation, global budgets, fee schedules, pay-for-performance incentives, and episode-based payments to providers.
History Taking In a Patient with Hemophilia
(1) Mahmoud Bikheet Ahmed, a 12-year-old male student, presented with bluish discoloration around his left eye following trauma 2 days prior.
(2) He has a known history of hemophilia and received cryoprecipitate for swelling and limited vision in his left eye as well as hemarthrosis in his left knee and elbow.
(3) His past medical history is significant for severe bleeding after circumcision at 6 months old when he was diagnosed with hemophilia A, and treatment for hepatitis C.
Dr. RAHUL VC TIWARI, SIBAR INSTITUTE OF DENTAL SCIENCES, GUNTUR, ANDHRA PRADE...
Dr. RAHUL VC TIWARI, SIBAR INSTITUTE OF DENTAL SCIENCES, GUNTUR, ANDHRA PRADE...CLOVE Dental OMNI Hospitals Andhra Hospital
This document presents a case report of a 22-year-old male patient who experienced trauma to the right side of his face after a motorcycle accident 20 days prior. He presented with pain and swelling in his right lower jaw. Physical examination revealed a laceration on the right eyebrow that was healing, subconjunctival hemorrhage on the right side, and loss of the malar prominence on the right side. Radiological investigations showed a zygomatic complex fracture and mandibular angle fracture on the right side. The treatment plan was for open reduction and internal fixation surgery to repair the fractures.Jessica Resume
Jessica Hughes is an LPN with over 10 years of experience providing culturally competent care to diverse patients with various needs including hospice, palliative care, wound care, diabetes, stroke, and psychiatric patients. She has strong clinical and organizational skills including monitoring vitals, administering medications and treatments, assisting with admissions and care plans, and ensuring quality patient care. Her professional experience includes working as an LPN at various facilities such as VA medical centers, nursing care services, and assisted living facilities.
Sicu Intro Bioethics
The document provides an introduction to bioethics and outlines several key topics including informed consent, advance directives, medical futility, Do Not Resuscitate (DNR) orders, confidentiality, and research. It discusses the role of the Department of Bioethics in providing ethics consultations and summaries key policies and guidelines related to complex ethical issues that may arise in patient care.
Midlevel Operations: Exploring New Expsoures with Allied Health Providers
Jayme T. Vaccaro, J.D.
Director, Professional Liability Claims
Sedgwick Claims Management Services, Inc.
Jayme.Vaccaro@sedgwickcms.com
www.sedgwick.com
Consumer Protection Act & Medical Negligence in Obstetrics & Gynecology : D...
Consumer Protection Act & Medical Negligence Obstetrics & Gynecology
How to protect Doctors from medico-legal litigations
Advanced Cancer at End of Life
A patient case study provides the foundation to explore functional status and prognosis in advanced cancer, with hospice as the active plan of care.
Alternatives evidence based_medicine
This document outlines various alternatives to evidence-based medicine that some physicians may use in practice when evidence is lacking, including experience-based, appearance-based, communication-based, and belief-based approaches. It provides examples of how factors like a doctor's age, hair, race, beauty, gender, smile, dress, use of ties, white coat, pens, stethoscope, glasses, voice, listening skills, confidence, and more may influence patient care when true evidence and scientific research are absent. The document also discusses religion-based, celebrity-based, and pharmaceutical marketing-influenced alternatives to evidence.
12SOAP Note Patient with UTIUnited State
1
2
SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.
Client’s Initials: L.U
Age :65 years.
Race: African American
Gender: Female
Date of Birth: 08
Insurance: BlueCross BlueShield .
Marital Status: Married
Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.
CC: Pain and burning during urination.
HPI:
Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.
ROS
Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.
Eyes: Denies double vision, change in vision factors, or blurry vision.
Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.
Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.
Pulmonary: Denies
Gastrointestinal: c/o moderate to severe pain in the abdominal area.
Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.
Musculoskeletal: Denies any kind of pain
Integumentary & breast: Denies issues
Neurological: Denies issues
Psychiatric: Denies any kind of depression or mood swing
Endocrine: Denies having any problem
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Known allergy
Past Medical History:
· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.
· Denies history of chronic medical problems with father or mother.
· Preventative care: None indicated
· Surgeries: Denies
· Hospitalizations: Denies
· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.
Allergies: No known food or drug allergy
· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...
12SOAP Note Patient with UTIUnited State
1
2
SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.
Client’s Initials: L.U
Age :65 years.
Race: African American
Gender: Female
Date of Birth: 08
Insurance: BlueCross BlueShield .
Marital Status: Married
Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.
CC: Pain and burning during urination.
HPI:
Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.
ROS
Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.
Eyes: Denies double vision, change in vision factors, or blurry vision.
Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.
Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.
Pulmonary: Denies
Gastrointestinal: c/o moderate to severe pain in the abdominal area.
Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.
Musculoskeletal: Denies any kind of pain
Integumentary & breast: Denies issues
Neurological: Denies issues
Psychiatric: Denies any kind of depression or mood swing
Endocrine: Denies having any problem
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Known allergy
Past Medical History:
· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.
· Denies history of chronic medical problems with father or mother.
· Preventative care: None indicated
· Surgeries: Denies
· Hospitalizations: Denies
· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.
Allergies: No known food or drug allergy
· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...
Clinical Method - Patient history taking procedures
The document discusses principles and components of history taking in clinical practice. It provides details on how to conduct a thorough history of present illness, including general interrogation, symptom analysis using frameworks like OPQRST and OLD CARTS, and systemic review. It emphasizes the importance of properly organizing the clinical approach and establishing good patient-doctor rapport when obtaining a patient's history.
15_224 - SAMPLE - Medical Chronology
The document is a medical chronology for Robert Seeger that outlines his medical history and treatment for a sacral pressure ulcer. It provides a brief summary of his hospitalizations and wound care from September 2014 to April 2015. During this time, he developed a stage III sacral pressure ulcer that progressed to stage IV and required multiple hospitalizations for debridement, wound closure procedures, and wound care. He was discharged to rehabilitation and nursing facilities at various points for wound management.
L-19 Breaking Bad News (prof. Faisal Ghani)
Lecture on the definition and the principles of Breaking Bad News in clinical practice, prepared and presented by Prof. Faisal Ghani to Alfarabi Medical College Students
Test Slides
This PPT is all about Something that we want to lear an discover new things in life which might be very useful and essential to do something so you can figure out and work on it so you will be able to do it simply great and awesome in life. After downlading the ppt please do not forget to reshare it with your friends families and morel
L-19 Truth Telling & breaking bad news (BBN) (Prof.faisal)
Lecture on truth telling and breaking bad news to patients. It was presented by Prof Faisal Ghani for Farabi Medical College medical students.
20120425 - USMLE Bioethics - Professional Behavior
The document summarizes key principles regarding professional behavior and ethics for physicians. It discusses appropriate boundaries in physician-patient relationships, informed consent, medical errors and liability, and obligations to report issues like abuse or impaired colleagues. Physicians must prioritize patient welfare, maintain open communication, and follow standards of care to practice ethically and avoid legal issues.
Advanced Cancer at End of Life
This webinar provides insight and guidance into the challenges of advanced cancer in patients nearing the end of life.
1[Shortened Title up to 50 Characters]2Week 9 Assignment.docx
1
[Shortened Title up to 50 Characters] 2Week 9 Assignment
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
July 31, 2016
Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care. Comment by DeAllen B Millender: Good introduction.
General Patient Information
Age: 41-year-old
Race/Ethnicity: Hispanic American
Partner Status: Married Comment by DeAllen B Millender: This information is not in APA format.
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills.
Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.
Duration: 5 to7 days du ...
1[Shortened Title up to 50 Characters]16Week 9 Assignment.docx
1
[Shortened Title up to 50 Characters] 16Week 9 Assignment
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
July 31, 2016
Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care. Comment by DeAllen B Millender: Good introduction.
General Patient Information
Age: 41-year-old
Race/Ethnicity: Hispanic American
Partner Status: Married Comment by DeAllen B Millender: This information is not in APA format.
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills.
Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.
Duration: 5 to7 days d ...
Introduction to Physical Diagnosis d.pptx
The document provides an introduction to physical diagnosis in clinical medicine. It discusses the importance of both the art and science of medicine. The medical art involves skills like interviewing patients, using senses to identify abnormalities, and clinical reasoning. A thorough history is important, including the chief complaint, history of present illness, past medical history, review of systems, and social/family history. The physical exam involves looking, touching, hearing and smelling. Laboratory tests can provide supporting evidence but should not replace clinical assessment. Building rapport with patients and maintaining ethics and confidentiality are also discussed.
History taking
History taking is a critical process for physicians to obtain useful information from patients to formulate diagnoses and provide medical care. It involves asking specific questions to gain information about a patient's chief complaint, history of present illness, past medical history, family history, and systems review. An accurate history obtained through good communication skills is important, as the diagnosis can often be determined from the history alone in about 70% of cases. The history should be taken in a structured manner, with open-ended questions to allow the patient to provide their full account before asking focused questions.
4. Medical Malpractice and Medical Records.pptx
Malpractice should not allowed in the field of medicine because your are dealing with humans life.
The malpractice is due to lack of doctors knowledge, uninteresting the sensitive cases, not using a guidelines.
The most type and common error in malpractice is the medication error and could put the patient's life risky.
Medical record is important why because you follow up the patients and will help you to guide and known the status the patient whether he or she improving or not.
There are several types of medical record: by using paper or documented book or by using electronic such as computers and so on.
If you are recording the patient information the patient will trust you and so happy because you still remember him or her information and this is good for you.
Top Effective Soaps for Fungal Skin Infections in India
Swisschem Dermacare has mentioned the List of The Best Antifungal Soap In India 2022. All of these soaps are trusted by various Dermatology Experts.
Cell Therapy Expansion and Challenges in Autoimmune Disease
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
More Related Content
Similar to Documentation in Healthcare
Sicu Intro Bioethics
The document provides an introduction to bioethics and outlines several key topics including informed consent, advance directives, medical futility, Do Not Resuscitate (DNR) orders, confidentiality, and research. It discusses the role of the Department of Bioethics in providing ethics consultations and summaries key policies and guidelines related to complex ethical issues that may arise in patient care.
Midlevel Operations: Exploring New Expsoures with Allied Health Providers
Jayme T. Vaccaro, J.D.
Director, Professional Liability Claims
Sedgwick Claims Management Services, Inc.
Jayme.Vaccaro@sedgwickcms.com
www.sedgwick.com
Consumer Protection Act & Medical Negligence in Obstetrics & Gynecology : D...
Consumer Protection Act & Medical Negligence Obstetrics & Gynecology
How to protect Doctors from medico-legal litigations
Advanced Cancer at End of Life
A patient case study provides the foundation to explore functional status and prognosis in advanced cancer, with hospice as the active plan of care.
Alternatives evidence based_medicine
This document outlines various alternatives to evidence-based medicine that some physicians may use in practice when evidence is lacking, including experience-based, appearance-based, communication-based, and belief-based approaches. It provides examples of how factors like a doctor's age, hair, race, beauty, gender, smile, dress, use of ties, white coat, pens, stethoscope, glasses, voice, listening skills, confidence, and more may influence patient care when true evidence and scientific research are absent. The document also discusses religion-based, celebrity-based, and pharmaceutical marketing-influenced alternatives to evidence.
12SOAP Note Patient with UTIUnited State
1
2
SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.
Client’s Initials: L.U
Age :65 years.
Race: African American
Gender: Female
Date of Birth: 08
Insurance: BlueCross BlueShield .
Marital Status: Married
Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.
CC: Pain and burning during urination.
HPI:
Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.
ROS
Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.
Eyes: Denies double vision, change in vision factors, or blurry vision.
Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.
Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.
Pulmonary: Denies
Gastrointestinal: c/o moderate to severe pain in the abdominal area.
Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.
Musculoskeletal: Denies any kind of pain
Integumentary & breast: Denies issues
Neurological: Denies issues
Psychiatric: Denies any kind of depression or mood swing
Endocrine: Denies having any problem
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Known allergy
Past Medical History:
· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.
· Denies history of chronic medical problems with father or mother.
· Preventative care: None indicated
· Surgeries: Denies
· Hospitalizations: Denies
· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.
Allergies: No known food or drug allergy
· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...
12SOAP Note Patient with UTIUnited State
1
2
SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.
Client’s Initials: L.U
Age :65 years.
Race: African American
Gender: Female
Date of Birth: 08
Insurance: BlueCross BlueShield .
Marital Status: Married
Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.
CC: Pain and burning during urination.
HPI:
Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.
ROS
Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.
Eyes: Denies double vision, change in vision factors, or blurry vision.
Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.
Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.
Pulmonary: Denies
Gastrointestinal: c/o moderate to severe pain in the abdominal area.
Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.
Musculoskeletal: Denies any kind of pain
Integumentary & breast: Denies issues
Neurological: Denies issues
Psychiatric: Denies any kind of depression or mood swing
Endocrine: Denies having any problem
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Known allergy
Past Medical History:
· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.
· Denies history of chronic medical problems with father or mother.
· Preventative care: None indicated
· Surgeries: Denies
· Hospitalizations: Denies
· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.
Allergies: No known food or drug allergy
· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...
Clinical Method - Patient history taking procedures
The document discusses principles and components of history taking in clinical practice. It provides details on how to conduct a thorough history of present illness, including general interrogation, symptom analysis using frameworks like OPQRST and OLD CARTS, and systemic review. It emphasizes the importance of properly organizing the clinical approach and establishing good patient-doctor rapport when obtaining a patient's history.
15_224 - SAMPLE - Medical Chronology
The document is a medical chronology for Robert Seeger that outlines his medical history and treatment for a sacral pressure ulcer. It provides a brief summary of his hospitalizations and wound care from September 2014 to April 2015. During this time, he developed a stage III sacral pressure ulcer that progressed to stage IV and required multiple hospitalizations for debridement, wound closure procedures, and wound care. He was discharged to rehabilitation and nursing facilities at various points for wound management.
L-19 Breaking Bad News (prof. Faisal Ghani)
Lecture on the definition and the principles of Breaking Bad News in clinical practice, prepared and presented by Prof. Faisal Ghani to Alfarabi Medical College Students
Test Slides
This PPT is all about Something that we want to lear an discover new things in life which might be very useful and essential to do something so you can figure out and work on it so you will be able to do it simply great and awesome in life. After downlading the ppt please do not forget to reshare it with your friends families and morel
L-19 Truth Telling & breaking bad news (BBN) (Prof.faisal)
Lecture on truth telling and breaking bad news to patients. It was presented by Prof Faisal Ghani for Farabi Medical College medical students.
20120425 - USMLE Bioethics - Professional Behavior
The document summarizes key principles regarding professional behavior and ethics for physicians. It discusses appropriate boundaries in physician-patient relationships, informed consent, medical errors and liability, and obligations to report issues like abuse or impaired colleagues. Physicians must prioritize patient welfare, maintain open communication, and follow standards of care to practice ethically and avoid legal issues.
Advanced Cancer at End of Life
This webinar provides insight and guidance into the challenges of advanced cancer in patients nearing the end of life.
1[Shortened Title up to 50 Characters]2Week 9 Assignment.docx
1
[Shortened Title up to 50 Characters] 2Week 9 Assignment
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
July 31, 2016
Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care. Comment by DeAllen B Millender: Good introduction.
General Patient Information
Age: 41-year-old
Race/Ethnicity: Hispanic American
Partner Status: Married Comment by DeAllen B Millender: This information is not in APA format.
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills.
Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.
Duration: 5 to7 days du ...
1[Shortened Title up to 50 Characters]16Week 9 Assignment.docx
1
[Shortened Title up to 50 Characters] 16Week 9 Assignment
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
July 31, 2016
Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care. Comment by DeAllen B Millender: Good introduction.
General Patient Information
Age: 41-year-old
Race/Ethnicity: Hispanic American
Partner Status: Married Comment by DeAllen B Millender: This information is not in APA format.
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills.
Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.
Duration: 5 to7 days d ...
Introduction to Physical Diagnosis d.pptx
The document provides an introduction to physical diagnosis in clinical medicine. It discusses the importance of both the art and science of medicine. The medical art involves skills like interviewing patients, using senses to identify abnormalities, and clinical reasoning. A thorough history is important, including the chief complaint, history of present illness, past medical history, review of systems, and social/family history. The physical exam involves looking, touching, hearing and smelling. Laboratory tests can provide supporting evidence but should not replace clinical assessment. Building rapport with patients and maintaining ethics and confidentiality are also discussed.
History taking
History taking is a critical process for physicians to obtain useful information from patients to formulate diagnoses and provide medical care. It involves asking specific questions to gain information about a patient's chief complaint, history of present illness, past medical history, family history, and systems review. An accurate history obtained through good communication skills is important, as the diagnosis can often be determined from the history alone in about 70% of cases. The history should be taken in a structured manner, with open-ended questions to allow the patient to provide their full account before asking focused questions.
4. Medical Malpractice and Medical Records.pptx
Malpractice should not allowed in the field of medicine because your are dealing with humans life.
The malpractice is due to lack of doctors knowledge, uninteresting the sensitive cases, not using a guidelines.
The most type and common error in malpractice is the medication error and could put the patient's life risky.
Medical record is important why because you follow up the patients and will help you to guide and known the status the patient whether he or she improving or not.
There are several types of medical record: by using paper or documented book or by using electronic such as computers and so on.
If you are recording the patient information the patient will trust you and so happy because you still remember him or her information and this is good for you.
Similar to Documentation in Healthcare (20)
Midlevel Operations: Exploring New Expsoures with Allied Health Providers
Midlevel Operations: Exploring New Expsoures with Allied Health Providers
Consumer Protection Act & Medical Negligence in Obstetrics & Gynecology : D...
Consumer Protection Act & Medical Negligence in Obstetrics & Gynecology : D...
Clinical Method - Patient history taking procedures
Clinical Method - Patient history taking procedures
L-19 Truth Telling & breaking bad news (BBN) (Prof.faisal)
L-19 Truth Telling & breaking bad news (BBN) (Prof.faisal)
20120425 - USMLE Bioethics - Professional Behavior
20120425 - USMLE Bioethics - Professional Behavior
1[Shortened Title up to 50 Characters]2Week 9 Assignment.docx
1[Shortened Title up to 50 Characters]2Week 9 Assignment.docx
1[Shortened Title up to 50 Characters]16Week 9 Assignment.docx
1[Shortened Title up to 50 Characters]16Week 9 Assignment.docx
Recently uploaded
Top Effective Soaps for Fungal Skin Infections in India
Swisschem Dermacare has mentioned the List of The Best Antifungal Soap In India 2022. All of these soaps are trusted by various Dermatology Experts.
Cell Therapy Expansion and Challenges in Autoimmune Disease
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Journal Article Review on Rasamanikya
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Efficacy of Avartana Sneha in Ayurveda
Avartana Sneha is a unique method of Preparation of Sneha Kalpana in Ayurveda, mainly it is indicated for the Vataja rogas.
Hemodialysis: Chapter 4, Dialysate Circuit - Dr.Gawad
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Best Ayurvedic medicine for Gas and Indigestion
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Light House Retreats: Plant Medicine Retreat Europe
Our aim is to organise conscious gatherings and retreats for open and inquisitive minds and souls, with and without the assistance of sacred plants.
Integrating Ayurveda into Parkinson’s Management: A Holistic Approach
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Histololgy of Female Reproductive System.pptx
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Phone Us ❤8107221448❤ #ℂall #gIRLS In Dehradun By Dehradun @ℂall @Girls Hotel...
Phone Us ❤8107221448❤ #ℂall #gIRLS In Dehradun By Dehradun @ℂall @Girls Hotel...chandankumarsmartiso
Phone Us ❤8107221448❤ #ℂall #gIRLS In Dehradun By Dehradun @ℂall @Girls Hotel With 100% Satisfaction
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
Learn about body grief and ways to cope with it. We will also explore methods to heal from this challenging experience.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Novas diretrizes da OMS para os cuidados perinatais de mais qualidadeProf. Marcus Renato de Carvalho
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
share - Lions, tigers, AI and health misinformation, oh my!.pptx
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Recently uploaded (20)
Top Effective Soaps for Fungal Skin Infections in India
Top Effective Soaps for Fungal Skin Infections in India
Cell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune Disease
Thyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptx
Thyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptx
Hemodialysis: Chapter 4, Dialysate Circuit - Dr.Gawad
Hemodialysis: Chapter 4, Dialysate Circuit - Dr.Gawad
Light House Retreats: Plant Medicine Retreat Europe
Light House Retreats: Plant Medicine Retreat Europe
Integrating Ayurveda into Parkinson’s Management: A Holistic Approach
Integrating Ayurveda into Parkinson’s Management: A Holistic Approach
Phone Us ❤8107221448❤ #ℂall #gIRLS In Dehradun By Dehradun @ℂall @Girls Hotel...
Phone Us ❤8107221448❤ #ℂall #gIRLS In Dehradun By Dehradun @ℂall @Girls Hotel...
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
share - Lions, tigers, AI and health misinformation, oh my!.pptx
share - Lions, tigers, AI and health misinformation, oh my!.pptx
Muscles of Mastication by Dr. Rabia Inam Gandapore.pptx
Muscles of Mastication by Dr. Rabia Inam Gandapore.pptx
Documentation in Healthcare
- 1. DOCUMENTATION – IN HEALTHCARE Topics covered: * WHY * WHEN * HOW * WHO * WHERE Speaker: Dr. Sushmita Biswas MBBS-DLO-MBA(HEALTHCARE)
- 4. • Fosters quality and continuity of care to the patient • Establishes an effective communication amongst the healthcare providers • Its speaks much louder than our vocal cords, and it speaks for years till the document is preserved • Serves as an evidence in the court of LAW
- 5. MANY PHYSICIANS COMPLAIN THAT THEY DO NOT HAVE THE TIME TO WRITE NOTES. “WOULD YOU RATHER SPEND THE TIME IN COURT FOR 12 WEEKS, 5 DAYS A WEEK, FROM 9AM TO 5 PM?” Boschert, Sherry ; Documentation do’s and dont’s can derail a lawsuit, 2005, OB/GYN News
- 6. AT THE FIRST POINT OF CONTACT & AT EVERY POINT OF CONTACT
- 7. SOAP Notes New SOOOAAP notes
- 8. S SUBJECTIVE • Chief complaints • H/O present illness • Past illness • Drug history +/- allergy • Medical history/Co-morbidities • Family history • Addictions O OBJECTIVE • Vital signs • General examination • Local examination(if any) • Systemic examination- all four systems A ASSESSMENT Provisional Diagnosis Differential Diagnosis Final Diagnosis P PLAN • Investigations • Monitoring instructions • Medicines • Patient/relatives communication & education • Follow ups
- 9. S- Subjective O- Objective O- Opinion O- Options A- Advice A- Agreed plan
- 10. Time and Date your( with name in BLOCK LETTERS & signature) entries LEGIBLE WRITING Destroy evidence Mention significant positive & negative entries : History & Examination Change records: sophisticated technology can detect alteration of records Label any addition as “ Late Entry” Peer review comments DO’s DON’T’s
- 11. A surgeon was held to be guilty of negligence for conducting sterilization operation during caesarian without obtaining consent. A gynecologist has been sued heavily as she was found guilty of performing abdominal hysterectomy instead of vaginal hysterectomy. Wrong site, Wrong side, Wrong person The court has held a consent given for excision biopsy, cannot by inference be taken as implied consent for surgery Case of Negligence: Tumour mistaken for fetus Failure to document non- compliance & lack of informed refusal : physician is considered guilty
- 12. A senior colleague documented as “ovarian cyst” was fabricated as “twisted ovarian cyst” by a junior colleague and opened the abdomen to find a fetus of 28 weeks gestational age. This case was a near miss from the blind eyes of the Judicial lady. Allegations & trial set in for FAILURE OF DIAGNOSIS OF HERPES SIMPLEX VIRUS, IMPROPER PRESCRIPTION OF TOPICAL STEROID leading to Keratitis…called for a penalty of 25 lacs to the treating physician. A male patient after a successful revival Post CPR, the patient sued against the hospital for giving him two huge scars on his chest, because the paddles w ere not jellied. Penalty of 25 Lacs on the hospital in 2004.
- 13. INFORMED CONSENT: • To be taken and signed by the SURGEON herself/himself • From the patient (Exceptions:in cases of mental disorder or minor or comatose) • A consent which is not properly informed is vulnerable for law suits ( ie expected complications or expected change of plan in surgery should be informed & documented).
- 14. Failed consent in cases of emergency or unconsciousness : * all considerations regarding consent will be set aside to save the life of a patient, to save him from permanent disability or/ and suffering. * should be countersigned by board of 3 people in life saving procedures.
- 15. Informed Consent is mandatory before: * Any invasive (major/minor) procedure/activity * Blood Transfusion * Restraint consent * Pre-operative & pre- anaesthetic consent * Intra-operative change in plan needs a formal consent
- 22. If it is NOT documented Then it is NOT DONE If it cannot be Understood Then it DID NOT HAPPEN If it cannot be read Then it DID NOT HAPPEN & If it DID NOT HAPPEN Then it should NOT BE PAID If there is ANY complication because either appropriate action not taken or not documented Vulnerable for LEGAL PUNISHMENTS